Mason, Elizabeth # 1fl,
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
s Name First Middle Last Sex
Elizabeth Joyce Mason Female
iiig Date of Death Age If Veteran of U.S. Armed Forces,
liii 11 /27/2017 80 yrs. War or Dates No
Place of Death Town of Hospital, Institution or Heritage Commons
City, Town or Village Ticonderoga Street Address Residential Health Care
Manner of Death El-Natural Cause El Accident Homicide El Suicide El Undetermined �Pending
la Circumstances Investigation
ut Medical Certifier Name Title
Richard McKeever M.D.
Address
1019 Wicker Stree , Ticonderoga, NY 12RR
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1564 46
Burial Date Cemetery or Crematory
11 /28/2017 Pine view Crematory
'' ❑Entombment Address
Cremation Oueensbury, New lark_
Date Place Removed
❑Removal and/or Held
and/or Address
E Hold
Date Point of
Q Transportation Shipment
t by Common Destination
im Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
p. Permit Issued to Registration Number
>< Name of Funeral Home Wilcox & Regan funeral home 01 R21%
Address
> 11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
IAddress .
7711 Permission is hereby granted to dispose of the human re ains desc ibed above as indicated.
3 Date Issued 11 /28/2017 Registrar of Vital Statistics_ !-y t� CZ
(sign re
District Number Place
gi
_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ut Date of Disposition Ii i lift) Place of Disposition .64.4 Left.—
3 (address)
VA
fC (section) Jdlot nwmber) (grave number)
flName of Sexton or Person in Charge of Pre ises `A S"°'40-
Z (pl se print)
111 i Li Title irk '4Pt
>: Signature
(over)
DOH-1555 (02/2004)